Choosing Wisely and

Healthcare Resource Stewardship Council (HRSC)

PGIP MeetingDecember 6, 2013

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Why stewardship? Why now?• Health care expenditures are increasing at unsustainable rates

• Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011

• There is waste in the health care system—some say as much as 30%

Jack Wennberg, Dartmouth Center for the Evaluative Clinical Sciences.

• One third of all physicians acquiesce to patient requests for tests and procedures—even when they know they are not necessary

Campbell EG, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007; 147(11):795-802

• Physician decisions account for 80% of all health care expenditures

Crosson FJ. Change the microenvironment. Modern Healthcare and The Commonwealth Fund [Internet]. 2009; Apr 27

Excess Cost Domain Estimates

IOM. The Healthcare Imperative, 2010.

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Overriding Issues in Health Care

• Issue of the decade starting in 2000: quality of care and patient safety

• Issue of the decade starting in 2010: decreasing the cost of care

• Recent initiatives have called on physicians to reduce waste and exercise wise stewardship of resources.

• ABIM Foundation. Choosing wisely• American College of Physicians. High value

care• AMA Council on Ethical and Judicial Affairs.

Physician stewardship of health care resources

• Joint Commission & AMA. Two leading health care quality organizations hold national summit to build consensus around ways to minimize overuse of five

treatments.

Are We Willing (and Able) to Address the Problem?

Healthcare Resource Stewardship Council• Initially organized by BCBSM in 2011 to focus on the access to

and affordability of care for Michigan citizens now and far into the future

• Purpose: – To engage in collaborative efforts to ensure judicious use and

active stewardship of health care resources.• Organizing principles:

– Principles and governance set by PGIP community leaders– Large scale representation from PGIP POs – Integrate hospitals, patients, systems, and employer groups in

future

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Healthcare Resource Stewardship Council

• Current status: – 26 PGIP POs engaged in initial planning sessions– Vision and core tenets established in 2012 (see next

slide)– HRSC Core Group and Value Partnerships meet

monthly– Working with the Michigan Data Collaborative to

establish a data reporting tool for PGIP POs to determine compliance rates with Choosing Wisely® guidelines

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Organize care to put patients first while making wise choices about care and the use of healthcare resources .

CORE TENETS

COMMUNICATION ACCESS ADVOCACY EMPOWERMENT

HRSC Vision and Core Tenets

WHAT DOES SUCCESS LOOK LIKE?• Movement from individual care

to population management• All partners in healthcare

delivery are empowered, engaged and aligned

WHAT WILL WE ACCOMPLISH?• Culture change• Philosophy change• Shift in accountability • Measurement to support the accountability• Payment reform to support the work and

accountability

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HRSC and Choosing Wisely®

• In 2012, HRSC identified focus areas from Choosing Wisely® guidelines

• Selected only guidelines that could be measured in BCBSM claims – Of those guidelines, HRSC identified those that:

• Have a high impact on cost• Are evidence-based• Are easily amenable to change

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Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.

Consumer Reports leads consumer communication efforts for this campaign.

Choosing Wisely

What is the Physician’s Role in Choosing Wisely?

The Charter’s commitment to a just distribution of finite resources specifically calls on physicians to be responsible for the appropriate allocation of resources and to scrupulously avoid superfluous tests and procedures.

Choosing Wisely PartnersSocieties Released Lists in April 2012 • American Academy of Allergy Asthma & Immunology• American Academy of Family Physicians• American College of Cardiology• American College of Physicians• American College of Radiology• American Gastroenterological Association• American Society of Nephrology• American Society of Nuclear Cardiology• American Society of Clinical Oncology

Societies Releasing Lists in Feb 2013 • American Academy of Hospice and Palliative Medicine• American Academy of Neurology• American Academy of Ophthalmology• American Academy of Otolaryngology-Head and Neck

Surgery• American Academy of Pediatrics• American College of Obstetricians and Gynecologists• American College of Rheumatology• American Geriatrics Society• American Society for Clinical Pathology• American Society of Echocardiography• American Urological Association• Society of Hospital Medicine• Society of Nuclear Medicine and Molecular Imaging• Society of Thoracic Surgeons• Society of Vascular Medicine

Societies Releasing Lists in Sept 2013 AMDA – Dedicated to Long Term Care Medicine - 9/4 American College of Surgeons - 9/4 Commission on Cancer – a multidisciplinary program of the American College of Surgeons

- 9/4 American Academy of Orthopedic Surgeons - 9/11 Society of General Internal Medicine - 9/12 American Psychiatric Association - 9/20 American Society for Radiation Oncology - 9/23 American Academy of Family Physicians** - 9/24 American College of Medical Toxicology and the

American Academy of Clinical Toxicology - 9/26

Societies Releasing Lists in Oct 2013 American Association for Pediatric Ophthalmology and Strabismus

- 10/8 North American Spine Society - 10/9 American College of Emergency Physicians - 10/14 American Association of Clinical Endocrinologists/

The Endocrine Society - 10/16 American College of Chest Physicians/

American Thoracic Society (Pulmonary) - 10/27 American College of Rheumatology* - 10/27 American Society of Dermatology - 10/29 American Society of Clinical Oncology* - 10/29 Society of Gynecologic Oncology - 10/31

Choosing Wisely Partners contd. • Consumer Groups Through Partnership with

Consumer Reports• AARP• Alliance Health Networks• Leapfrog Group• Midwest Business Group on Health• Minnesota Health Action Network• National Business Coalition on Health• National Business Group on Health• National Center for Farmworker Health• National Hospice and Palliative Care Organization• National Partnership for Women & Families• Pacific Business Group on Health• SEIU• Union Plus

•Wikipedia

November 2013• American Headache Society - 11/21

December 2013• American Society of Hematology - 12/4January 2014• American Association of Critical-Care Nurses/

American College of Chest Physicians/American Thoracic Society/Society of Critical Care Medicine (Critical Care) - 1/11

• Society for Cardiovascular Magnetic Resonance - 1/16February 2014• Society for Maternal-Fetal Medicine - 2/3 • Heart Rhythm Society - 2/10 • American College of Occupational and Environmental Medici

ne - 2/24

• The American Geriatrics Society* - 2/27 • American Academy of Allergy, Asthma & Immunology - 2/28Release Date TBD• American Association of Blood Banks • American Association of Neurological Surgeons • American Society of Anesthesiologists • American Society of Colon and Rectal Surgeons • American Society of Plastic Surgeons

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How the Lists Were Created

• Societies were free to determine the process for creating their lists

• Each item was within the specialty’s purview and control

• Procedures should be used frequently and/or carry a significant cost

• Should be generally-accepted evidence to support each recommendation

• Process should be thoroughly documented and publicly available upon request

Actions

Dozens of 2-Page Brochures(in plain English & Spanish)

HRSC Recommendations – Bundled Focus Areas

• ACR1 - Don't do imaging for uncomplicated headache• ACP2 - Don't obtain back imaging studies in patients with non-

specific low back pain• AAAI2 - Don't order sinus computed tomography (CT) or

indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis

Imaging of Uncomplicated Conditions

• ASNC1 - Don't perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present

• AAFP4 - Don't order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms

Cardiology Tests in Low-Risk Individuals

• AAFP5 - Don't perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease

• AAFP3 - Don't use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors

Women’s Health

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ANALYSIS• Lack of knowledge• Time constraints / Workflow disruption• Financial disincentives• Cost to develop and distribute materials

GOALS• Increased awareness• Decreased cost / capita

HRSC Choosing Wisely Guidelines A3BACKGROUND • Unsustainable “system” of increased costs• Unnecessary services (passive provider

involvement and waste/harm)• Uneducated consumer• Opportunity for education of providers, patients,

payers and employers

CURRENT CONDITIONS

Per Capita Spending Variations

SMART• Specific• Measurable• Actionable• Relevant• Achievable

FOLLOW-UP• Distribution of Tool• Engagement of stakeholders

RECOMMENDATIONSTOOLS (Reports and Decision Aids)• Handouts• AppSTRATEGIES• Engagement with community partners (e.g. GDAC)• Marketing (“jingle” – “We choose wisely together.”FINANCIAL• Incent for wiser decisions by providers and patients

PLANWhat / Who / When• Choosing Wisely analysis and dashboard

Choosing Wisely Reporting Tool

Ellen Bunting

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Finding the Choosing Wisely® Reporting Tool

1. PGIP Collaboration Site (must be a member of a participating PO and be registered to gain access)

2. Choose the Analytics Tab 3. Within Analytics choose MPAC4. Under MPAC Documents, click on Choosing Wisely Reporting

Tool

The tool will be available as of December 6, 2013.

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Choosing Wisely® Workgroup

• Convened by GDAHC and MSMS in June 2013• Workgroup comprised of various stakeholders• Goal to create uniform training curriculum for health

care professionals and consumers• Training aligns with HRSC recommendations:

Cardiology, Imaging and Women’s Health• Curriculum and lead trainers are ready to test the

tools and learning approach

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Gary Billotti

Choosing Wisely® through the Michigan Health Information Alliance

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• Choosing Wisely®: http://www.choosingwisely.org/

• ABIM Foundation: http://www.abimfoundation.org/

• Consumer Reports Health:http://consumerhealthchoices.org/campaigns/choosing-wisely/

• Ellen Bunting, Senior Business Analyst, Michigan Data Collaborativeebunting@med.umich.edu

• Sheri Lee, Senior Health Care Analyst, Value Partnershipsslee2@bcbsm.com

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